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I respond to this report here https://jasonstanleyantifascist.substack.com/p/on-the-philosophical-muddle-that
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Please watch the video before commenting. I would be interested to hear from philosophers who have thought about these issues, or from those knowledgeable about the practices in the Netherlands.
OK, I'm not an expert. I see three questions:
1. Is assisted suicide an appropriate case for 'medical self-determination'?
2. Even if so, should psychological conditions be included?
3. It seems that in every country where assisted suicide is legally permitted, the criteria, initially stringent, have been successively relaxed and broadened. Is this a 'good thing', and what are its public policy implications?
My views: I'm not sure about 1. I have my doubts. What if playing piano is someone's entire life and they decide that if they can't play because of an injury, they don't want to live? These things happen. I'd be inclined to deny AS in this case though I'm not sure. For instance, many people make a serious attempt at suicide and when the attempt fails, then go on to lead happy lives.
2. (psychological cases) I personally AM sure about. Any psychological condition severe enough that suicide is a better option, is severe enough to disqualify someone as a rational decision maker until they get better (when the question no longer arises.) This just doesn't feel right to me at all. While I don't doubt that the woman in the video experiences severe problems that seem hopeless to her, she does not seem like a hopeless case to me. Frankly I think the psychiatrists who told her she will never get better may be guilty of malpractice. She's 28, looks healthy, and seems to be taking good care of herself, and you want to write her off as 'hopeless'? And I doubt her 'autism' diagnosis. My nephew is autistic. I know what autism looks like, and it's not her. She's maybe 'Aspergers' at worst.
3. I checked the extraordinary statistic that 5.1% of deaths in the Netherlands are due to assisted suicide, and it is indeed accurate. That is WAY too many people. And I think there are severe negative consequences to the social 'normalization' of assisted suicide. There was a case from Canada where a disabled veteran trying to get a wheelchair ramp installed at her house was told by the VA: 'Sorry, we don't have the budget for that. But if your life is really so unbearable to you if you can't leave the house, we can arrange MAID (assisted suicide) for you if you like.' This is not even an outlier in Canada: there are several other similar cases involving the VA encouraging 'expensive' veterans to commit suicide.
SO: I think we're already much too far down the 'slippery slope' Is there a stable place where we can allow AS for really extreme cases (terminal cancer, unbearable pain) without people being tempted to broaden its range? I'm not sure: perhaps not, in which case I think the 'greater good' might be served by banning it altogether.
I don't have strong opinions on this particular kind of case, but in general, I'm in favor of assisted death when it honors patient autonomy and when death is good for the patient. Thus, the question for me is whether assisted death in cases of mental illness is consistent with those two fundamental values. My guess is that it can be.
What makes cases like this more ethically and emotionally difficult for me is that we can't predict whether any particular mental health patient will improve (or so I've heard). I know there are patients who've tried every treatment recommended to them, but there's a small part of me that wonders if they've really tried everything, including nonstandard treatments–e.g., psychedelics, acupuncture, reiki, etc.
Regarding this particular patient, I don't know her history, so my comments are necessarily limited. But if she's tried everything, and we're convinced that assisted death respects her autonomy, then my tentative position is that assisted death is justified in this case. Of course, this doesn't mean that any doctor must be forced to participate. I believe conscientious objection should be protected.
Just to flip the perspective a bit: is it really so obvious that having 94.9% of deaths be *unchosen* is "WAY too low"? Should we generally prefer death to be voluntary or involuntary?
Presumably the ideal would be for all involuntary causes of death to be abolished, leaving AS as the only cause of death, chosen whenever people are ready. Of course, we haven't abolished all those other causes of death, so too low a rate of natural death would seem to indicate over-use of AS. As the rest of your comment aptly explains, there are reasons to be concerned about whether AS may be pursued prematurely in some cases. But there are also (less saliently) reasons to be concerned about depriving people of this option in cases where it would benefit them — even cases that do not involve terminal illness, or "unbearable pain".
Overall, then, it just seems very unclear what the "ideal" level of AS *in our current societal circumstances* would be.
The woman featured in the video, who happens to be from my smallish hometown, would have to be suffering from “uitzichtloos en ondraaglijk lijden” [unbearable suffering with no chance for improvement] and there would have to no reasonable alternative to euthanasia as determined by three medical professionals with knowledge of the medical situation of the person making the request. A flowchart in Dutch https://richtlijnendatabase.nl/gerelateerde_documenten/f/17983/Stroomschema%20euthanasie%20verzoek.pdf
California provides empirical support for the idea that legislation covering physician aid-in-dying may be expanded over time. Since passage in 2016, the law has been amended to reduce some of the difficulties patients have had getting prescriptions. Recent amendments proposed by Senator Blakespear would go further and change the qualifying medical diagnoses from a "terminal disease" to a "grievous and irremediable medical condition." In practice, this legalese would likely entail a significant broadening of patients who qualify. Although "the bill would specify that a sole diagnosis of a mental disorder is not a grievous and irremediable medical condition," clinically speaking it is not difficult to imagine patients with severe mental health diagnoses experiencing physiologic effects that follow from them, such as severe malnutrition or, in the case of substance abuse disorder, organ dysfunction or failure. Only time would tell whether those patients would qualify given that they would have both a severe mental disorder and some other serious illness. The text is available here: https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=202320240SB1196
Looking at California specifically, the data shows an annual increase in patients dying from PAID: https://www.cdph.ca.gov/Programs/CHSI/CDPH%20Document%20Library/CDPH_End_of_Life%20_Option_Act_Report_2022_FINAL.pdf
However, the overall percentage is nowhere near comparable with what is reported here for the Netherlands. As one would expect, California saw considerable increases in deaths for the past few reported years, due to COVID. Taking 300,000 as an approximate regular annual figure, even the highest reported number of PAID deaths is about 0.003% of the overall.
There is something of a sad irony to see this video posted just a few days after the posting of Jonathan Bennett’s death:
https://leiterreports.typepad.com/blog/2024/04/in-memoriam-jonathan-bennett-1930-2024.html
In 2014 Bennett’s wife Gillian Bennett made a final post on her blog, it was titled “Goodbye and Good Luck”:
In this piece she explains her reasons for ending her own life – something that she had to do entirely on her own, since assisted suicide was prohibited in Canada until 2015.
Below I quote from a CBC article describing Bennett’s predicament and the choices that she faced:
________
‘In her note, Bennett suggests citizens should be legally obliged to make a Living Will, stating how they want to die and the circumstances under which they do not want to be resuscitated.
"My hope is that… the medical profession will mandate, through sensitive and appropriate protocols, the administration of a lethal dose to end the suffering of a terminally ill patient, in accordance with her Living Will," wrote Bennett.
Bennett added that they would have had their children join her husband at her side, but they did not wish to put them in jeopardy legally.
"This is all much tougher than it needs to be on Jonathan, and I wish he did not have to be alone with his wife's corpse," Bennett wrote.’
A new law, making assisted suicide legal for those whose death was reasonably foreseeable, was introduced in Canada in 2016. In 2021 the law was further amended by Bill C-7 to include those suffering from a grievous and irremediable condition whose death was not reasonably foreseeable. More details on the current Canadian situation can be found here: https://en.wikipedia.org/wiki/Euthanasia_in_Canada#Statistics
With regard to the video describing the case of Zoraya ter Beek and the situation in Holland there is much that could be said. Although the author is not named – or her qualifications mentioned – her name is Rupa Subramanya and she lives in Ottawa (Canada) where writes for the National Post (the main right wing newspaper).
Suffice it to say that her commentary strikes me as a tissue of confusion and over-simplification.
1. Subramanya begins her commentary by pointing out that ter Beek’s psychiatrist (who presumably knows ter Beek’s situation much better than Subramanya) arrived at the conclusion that her condition could not be improved. Subramanya suggests that in Holland people are choosing to end their life because of pain that “in many cases can be treated”. Does that mean that Subramanya and others like her have the right to deny ter Beek the right to decide for herself, subject to due process and deliberation, what options are best for her? The exact same argument could be – and has been – used to deny dementia patients such as Gillian Bennett the right to decide for herself whether continuing her life while suffering from dementia was acceptable or not.
2. In circumstances where individuals enjoy the right to (freely) choose the option of assisted euthanasia we can well expect that many will want and choose this option. Subramanya treats this as evidence of some decline of human values and respect for life. It is, in fact, the opposite of that. It is a sign that society respects the individual’s right to choose for herself when her life is or is not tolerable or worth continuing – a basic and fundamental human right.
3. The solution to social conditions that make life unbearable is not to deny people access to voluntary euthanasia or assisted suicide but to improve those social conditions – which may well prove to be a difficult and challenging task for society, never mind for the individual case. The worst option is to deny competent individuals the right to decide this for themselves while these conditions (individually or collectively) persist.
The legislation in Holland and Canada concerning assisted suicide may well need refinements of various kinds but, contrary to Subramanya’s glib commentary, these are measures that serve to secure a more humane society. A society that respects the dignity of the individual will not allow some to impose their judgments and values on the lives of others. In particular, this legislation removes social conditions that force a person to either suffer without remedy or find some brutal, messy way of ending their lives on their own.
This brings us back to the case of Gillian Bennett. Faced with social conditions that denied her any decent choice or option on this matter she had to find a way of ending her life without the aid and comfort of medical professionals. With the support of her husband Jonathan, and their children, she displayed remarkable courage and pointed the way forward for us all.
My first classes in Philosophy as a bright-eyed young undergraduate, I was so enthused that I imagined a grand future for philosophy. A future where philosophy professors with sound abilities in systematic moral reasoning and metaphysics, and perhaps, epistemology will guide humanity through problems such as suicide, assisted suicide. While I have no original views compelling enough to make individuals like the one mentioned in this video change their mind, I do not accept that the most realistic alternative for anyone (who is not faced with a terminal illness) is to kill themselves. But no, some of them are not killing themselves by themselves. Rather, they are legally encouraged to kill themselves- through the assistance of the State who has made it legal.
Even if we could solve the climate change problem, and manage to accept that AI is here to solve some of our problems (and not displace us completely), humanity still faces such a bleak future! As Camus stated in the Myth of Sisyphus, “There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.”
Granted we are able to solve the peripheral problems of climate change, AI risk, inequality, poverty, famine, etc., I do think that philosophy has a role to play in alleviating the human condition (particularly through therapeutic philosophy that nurtures the mental states of humans). Actually, philosophy has a role to play in solving even the peripheral problems!
While it may seem plausible that a "psychological condition severe enough that suicide is a better option, is severe enough to disqualify someone as a rational decision maker," laws in Canada and (I think) the USA do not require this connection. For instance, in Ontario suicidal people can be prevented from killing themselves without a finding of decisional incapacity. Under Ontario's Mental Health Act, a physician or justice of the peace may complete a form requiring the police to take an individual to a hospital, where the person is to be examined by psychiatrist. The person may then be held (and given treatments required for sustaining life) without a finding of incapacity. In fact, they may be assessed and NOT established to lack decisional capacity while still being required to remain in the hospital for weeks or months.
A sufficient condition for detaining someone under such a form is that he or she "has attempted or is attempting to cause bodily harm to himself or herself" (quoting from Ontario's Mental Health Act Form 1).
An upshot of Ontario's law is, "It doesn't matter if you're rationally competent — direct self-destruction just isn't allowed." Canada's federal MAID (Medical Assistance in Dying) law in effect qualifies such provincial laws by saying, "unless you meet these criteria, as determined by physicians:…." A libertarian might object to having to meet any government standards to opt for suicide, but each Canadian province has so far retained this degree of paternalism.
I've been surprised by the intensity of arguments for loosening Canada's MAID requirements. Any standard that excludes a group (e.g., minors or the mentally ill) is assailed as unjust discrimination. The attackers then appeal to mercy, asking how we can be so inhuman as to condemn the excluded class to suffer without the mercy of MAID. If you question whether the suffering really is unbearable, you're rebuked for arrogance — 'Who are you to judge this other's suffering as unworthy?' If you question whether it's irreversible, you're dismissed as lacking both scientific authority and the individual's first-hand knowledge of their condition. If you suggest the person's self-destruction would (in cases like the one shown in the video) involve rejecting a future of fairly robust autonomy and argue we've no right to such a wholesale surrender of autonomy, … well, in my experience advocates for loosening the criteria aren't convinced.
"3. The solution to social conditions that make life unbearable is not to deny people access to voluntary euthanasia or assisted suicide but to improve those social conditions – which may well prove to be a difficult and challenging task for society, never mind for the individual case. The worst option is to deny competent individuals the right to decide this for themselves while these conditions (individually or collectively) persist."
The problem with this is that the Powers That Be, rather than dealing with the intolerable conditions, may say 'Well, we're not going to fix it. And if you don't like it, you can always commit suicide.' So then the Powers That Be don't need to address the 'difficult and challenging task' of actually improving people's lives. This is not an academic point: there have already been quite a number of cases like this, particularly in Canada (there are some examples in my first two comments.)
One part of my bioethics class for over 20 years included a video "Choosing Death" by Frontline PBS made in 1993. It was an excellent piece on assisted euthanasia, then recently legalized in the Netherlands, involving cases that began with terminal illnesses but moved to ones that were much more problematic, including a non-symptomatic HIV case and a chronic anorexic who died in this manner. Mind you this is 30 years ago, so this is not novel moral territory there. It was one of the most powerful classes in that course, pitting questions about rational suicide against society's assessments of what constitutes permissible end-of-life decisions voluntary, questionably voluntary, and non-voluntary. The crucial question is that of legally enforced paternalism–clearly justified in resulting harm to others, but to what extent are we collectively required to prohibit harm to oneself in the face of a request for a more humane assisted death than by more traumatic self-inflicted means? I wonder if suicide stats, especially in the US involving our proliferation of the availability of guns, could be of any use here.
There is, I agree, a problem about individuals who are living in social conditions of various kinds that make their lives so miserable – through poverty, lack of medical care, etc. – that they no longer find their lives worth living. The question is how to effectively improve this situation, to the extent that this can be done. However…
1. It is not true that every case – or even most cases – fall into this sort of category. Sadly, there are many cases where individuals are suffering intolerable pain or misery that have no obvious, much less, immediate "cure" or "treatment" available to them.
2. Taking away an individual's right to decide what options are best for him or her is no solution. To remove a person's right to decide when/if her best option is to end her life with an empty and patronizing claim that (according to someone else) they have better options serves only to make their condition far worse.
3. There is a need for reliable, sensible safeguards to ensure that people making a difficult choice of this kind are fully informed, in a steady and stable state of mind, and in no way subject to coercion or pressure IF they decide to choose to end their lives. Care certainly needs to be given to the procedures involved in this. But that does not imply that others can decide for them – whatever their own preferences and values may be.
4. Finally, there is a notable pattern of opponents of MAID (in Canada), and of assisted suicide in general, to cite problem (hard) cases or cases where the process has failed and to use this as a wedge to discredit the entire system. What is really appalling and unconscionable is a society that compels individuals, who are enduring unbearable suffering and have no confidence that their situation will change or improve, either to carry on suffering or find means to end their lives without any support or comfort of a medical kind. How can that be presented as "caring" about people or valuing and respecting human life?
This is an interesting and troubling case to ponder. I have qualms about letting a 28-year-old get euthanasia for mental suffering. I do not have similar qualms for someone of much more advanced age and a terminal illness (e.g. a 90 year-old with terminal cancer) getting euthanized.
The more I have dwelt on this, the more I think the reason I have divergent intuitions on these two cases is not ethical but epistemological.
For someone who near the end of their natural lifespan and suffering from an incurable disease whose course of development is well-known, we can have a high degree of confidence that there is not much more life can offer them. The odds of my hypothetical nonagenarian bouncing back from stage 4 cancer and living another 20 fulfilling years are extremely poor.
In the case of the 28 year old with mental illnesses, I don't think we can be nearly so confident. Such a person has half a century or more of potential lifespan in front of them. A lot can happen in that time. With all due respect to psychiatrists, can they really be so confident in their prognosis for a patient's next fifty-plus years as to say that they have no hope of recovery or improvement? I am admittedly not an expert, but I would greet such a pronouncement with great skepticism.
We have an interesting court case going on in The Netherlands, about a cooperation that supplied a drug that supposed to lead to an easy death. It is really fascinating
There is simply no need for physicians (or the state, or the taxpayers via the state) to expose themselves to such moral risk as in the article. Unless the suicidal person is severely physically impaired, they face no great (physical) difficulty in ending their own life. (If a given state permits or requires the use of state force to prevent this, that is reason to change that law, not reason supporting the euthanasia law.)
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